Improving Chronic Illness Care
Improving Chronic Illness Care

Overview

The improvement sequence begins when a motivated practitioner wants to change chronic care processes.

The first step is to familiarize your entire team with two key improvement strategies:

the Chronic Care Model as a system for redesigning your current care delivery, and the Model for Improvement as a quality improvement strategy that teaches the team how to make rapid changes to their practice. Read more...
 

Two:  Organize your care team

by assigning clear roles and responsibilities in the care of patients with chronic illness. Much in the same way the team is organized to handle an acute event like a laceration, the team knows who does what and when at the time of the chronically ill patient visit. Read more...
 

Three:  Adopt and/or adapt existing disease-specific guidelines

for the condition of interest. These guidelines can be adopted from national, regional or local sources depending on the provider’s needs and situation. Read more...
 

Four:  Get to know your patient population’s care needs

Being able to identify all members of the condition population along with their key clinical data allows the provider to begin planning for systems that ensure deliver of evidence-based clinical care on a regular, proactive basis. Building a database to store the data for use during future visits and for performance reporting is absolutely essential to successful improvement. Read more...
 

Five:  Choose measures to track your improvements

These measures relate to the clinical priorities outlined in the adopted guideline. Read more...
 

Six:  Plan care

Conducting planned patient visits generated by the practice helps you better manage their chronic care needs without the noise inherent in the acute care visit generated by the patient. The process for conducting planned visits is described in the pages to come. Read more...
 

Seven:  Provide self-management support to patients at every visit

The patient becomes empowered to be responsible for their health. The care team works with patient to collaboratively set realistic goals, and follow-up regularly to problem-solve barriers and set new goals as appropriate.

The successful provider team will start with one patient and test changes to the delivery of care. Building on successful changes with successive patients leads to a system implemented for all patients, regardless of condition or disease. As your team tests new ways of delivering care and implements the successful changes, there must be ongoing training for all staff and a malleable performance feedback system to inform continued improvement.

Once the processes for a proactive visit are in place, the team can begin to address patient needs opportunistically. Many chronically ill patients will show up for acute care before the provider has a chance to schedule planned care. This is an opportunity to create systems to deliver as much of the routine chronic care as possible in the acute setting. Systems such as standing orders and reminders can help the provider “pack” the chronic care needs into the acute visit, and then ensure that planned visits are scheduled in the future. Read more... 

We will now guide you through each of the steps in detail.